CORONARY ARTERY BLOCKAGE

CORONARY ARTERY BYPASS GRAFTING

CURRENT AND POTENTIAL PROBLEM – Post Operative

Patient might experience these complications; Excessive bleeding after surgery. Myocardial infarction or heart attack. Respiratory insufficiency / pneumonia. Kidney failure. Heart arrhythmias, or irregular heartbeats. Infection of the breastbone or the sternum. Infection can affect incisions of the leg or the hands Stroke. Mood swings.

Persisting pain in breastbone.

NURSING MANAGEMENT

Preoperative Nursing Management.

Intraoperative Nursing Management.

Postoperative Nursing Management.

PREOPERATIVE NURSING MANAGEMENT

The preoperative nursing management

usually begins before hospitalization.

Patients with nonacute heart disease

may be admitted to hospital the day

before or the day of their surgery.

PREOPERATIVE ASSESSMENT

History

Physical examination

Radiographic examination

Electrocardiogram

PREOPERATIVE ASSESSMENT

Laboratory analysis

Typing and cross-matching of blood.

Assessing patient’s functional level

Psychosocial assessment.

Family support system

PHYSICAL EXAMINATION

General appearance and behavior

Vital signs

Nutritional and fluid status, weight and Height

Inspection and palpation of heart

PHYSICAL EXAMINATION

Auscultation of heart

JVP

Peripheral pulses.

Peripheral edema.

PSYCHOSOCIAL ASSESSMENT

Meaning of surgery to patient Coping mechanisms being used. Anticipated changes in lifestyle Support system in effect Fear regarding present & future Knowledge & understanding of surgical

procedure.

NURSING DIAGNOSIS

Fear related to surgical procedure, its uncertain outcome, and the threat of well-being.

Goal: To reduce fear.

INTERVENTIONS

Allowing patient and family to express their fears.

Explain the patient regarding surgery and sensations that are expected during and after the surgery.

Reassuring the patient that fear of pain is normal and explain that some pain will be experienced but certain measures will help to relieve the pain.

COMMUNICATION

INTERVENTIONS

Encourage the patient to talk about the fear of dying.

Patient should be reassured and misconceptions should be corrected.

NURSING DIAGNOSIS

Knowledge deficit regarding the surgical procedure and the postoperative course.

Goal: To provide the knowledge regarding surgery

INTERVENTIONS

Patient and family teaching about Hospitalization Surgery Length of surgery Expected pain and discomfort Critical care phase Recovery phase

PATIENT TEACHING

INTERVENTIONS

Physical preparation before surgery Medications before surgery Information regarding equipments, tubes

that will be present postoperatively Teaching the postoperative exercises. Outcome of the surgery

NURSING DIAGNOSIS

Potential for complications related to the stress of impending surgery (Angina, Severe anxiety, Cardiac arrest)

Goal: To monitor and manage the complications

INTERVENTIONS

Assess for complications Angina: oxygen therapy and

nitroglycerine therapy. Severe anxiety: emotional support Cardiac arrest: cardiac life support

INTRAOPERATIVE NURSING MANAGEMENT

Assisting in surgical procedure Continuous monitoring Monitoring for complications:

dysrhythmias, hemorrhage, MI, CVA, embolization etc.

INTRAOPERATIVE MANAGEMENT

POST OPERATIVE NURSING MANAGEMENT

ASSESSMENT: Neurological status Cardiac status Respiratory status Peripheral vascular status Renal function Fluid & electrolyte status

POST OPERATIVE ASSESSMENT Contd…

Pain Assessment of equipments and tubings Psychological and emotional status as

patient regains consciousness Assessing for complications.

ASSESSMENT

NURSING DIAGNOSIS

Decreased cardiac output related to blood loss and compromised myocardial function

Goal: To restore cardiac output

INTERVENTIONS

Monitor cardiovascular status Assess arterial pressure every 15 min.

until stable Ascultate for heart sounds and rhythms Assess all peripheral pulses Hemodynamic monitoring ECG monitoring

INTERVENTIONS

Assess cardiac enzymes Monitor urinary output Observe for persistent bleeding Observe for cardiac temponade Observe for cardiac failure Observe for myocardial infarction.

NURSING DIAGNOSIS

Risk for impaired gas exchange related to trauma of extensive chest surgery

Goal: To maintain adequate gas exchange

INTERVENTIONS

Maintain proper ventilation Monitor arterial blood gases, tidal

volumes, peek inspiratory pressures and extubation parameters

Auscultate chest for breath sounds Provide chest physiotherapy as

prescribed

INTERVENTIONS

Promote deep breathing coughing and turning, use of incentive spirometer.

Teach incisional splinting with a cough pillow to decrease discomfort during deep breathing and coughing

Suction tracheobronchial secretions as needed, using aseptic technique

EARLY AMBULATION

NURSING DIAGNOSIS

Risk for alteration in fluid volume and electrolyte balance related to alteration in blood volume

Goal: To maintain fluid and electrolyte balance

INTERVENTIONS

Maintain intake and output chart Assess the following parameters: LAP,

BP, CVP, PAWP, weight, electrolyte levels, hematocrit, JVP, tissue turgor, breath sounds, urinary output etc.

Measure post operative chest drainage Be alert to serum electrolyte levels

NURSING DIAGNOSIS

Pain related to operative trauma and pleural irritation caused by chest tubes

Goal: To relieve pain

INTERVENTION

Record nature, type, location and duration

Providing comfortable position Assist patient to differentiate between

surgical and anginal pain Administer prescribed pain medication Encourage relaxation techniques

PAIN MEDICATION

NURSING DIAGNOSIS

Risk for alteration in renal perfusion related to decreased cardiac output, hemolysis, or vasopressor therapy

Goal: To maintain adequate renal perfusion

INTERVENTION

Measure urine output strictly Monitor renal function tests Report to physician if urine output less Administer medications as prescribed

NURSING DIAGNOSIS

Risk for hypothermia/hyperthermia related to cardiopulmonary bypass surgery, infections etc.

Goal: To maintain normal body temperature

INTERVENTIONS

Warm the patient gradually with warm air or warm blankets or heat lamps

Assess for dysrythmias due to hypothermia

Assess for elevated body temperature Assess for infection ( lungs, urinary tract,

incisions and intravascular catheter

INTERVENTIONS

Use the aseptic technique while dressing and other procedure

Using proper hand washing technique Meticulous care to be taken to prevent

contamination at the sites of catheter and tube insertion

Care of the graft donor site.

CARE OF THE GRAFT DONOR SITE

RADIAL ARTERY

CARE OF CHEST TUBE

NURSING DIAGNOSIS

Risk for sensory- perceptual alterations related to sensory overload

Goal: to prevent postcardiotomy syndrome

INTERVENTIONS

Explain all procedures to patient Plan nursing care to provide for periods

of uninterrupted sleep with day-night pattern

Decrease sleep preventing environmental stimuli as much as possible

INTERVENTIONS

Promote continuity of care from nurse to nurse

Orient the patient to time, place and person. Encourage the family to visit at regular times

Teach relaxation and diversional techniques

Observe for signs of pericardiotomy syndrome

NURSING DIAGNOSIS

Knowledge deficit about self care activities

Goal: to help the patient in the performance of self care activities

INTERVENTIONS

Develop teaching plan for patient and family specifically about:

Diet Activity progression Exercise Deep breathing, coughing exercises Medication regimen Follow up

PATIENT HEALTH EDUCATION

For post operative care;

I. Wound care Do not wet the wound (first 3 weeks after surgery). Keep forearm / leg wounds dry. If wound get wet, immediately dap with dry towel. Use antiseptic soap when bath (after 3 weeks